EmailMe Form - Ballarat & District Trotting Club

Title *

Name *

First Last

Mobile Phone *

Home Phone

Email *

DOB *

DD / MM / YYYY

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Gender *

Male

Female

I wish to receive club newsletters and promotions, third party offers, and offers that include alcohol or gaming related activities *

Yes

No

Select membership programs you wish to join: *

Diamond Rewards (complimentary)

BDTC Club Membership ($25)

Trot Card Membership ($50)

Trainer Membership ($100)

Are you Part of a Sporting or Community Group *

No

Yes - Name Of Sporting/Community Group is:

**Player rewards (gaming machine players only) Government requirements

I agree to receive my Player Activity Statement, in accordance with governing legislation please select the box *

Via email

Via mail

From venue

How would you like to pay: *

Online (PayPal - No Account Needed)

Bank Transfer

Over the Phone

Cash or Cheque

Over the Phone Payments

Upon submitting this form, one of our staff members will contact you regarding payment.

Cash or Cheque

Payments can be made when collecting your membership card from the venue.

Bank Transfer

Banker Transfer: BDTC
BSB: 083526
ACCOUNT: 515 657 490
Please use name as reference

I am over the age of 18 and have received, carefully read and understood the Rules of the program(s). I agree to strictly abide by these Rules, as amended from time to time and declare that the details in this application are true and correct.
I understand and will adhere to the rules of the Ballarat & District Trotting Club at all times

Signature *

Clear

Click and hold mouse button to draw your signature